INSTALL_1994 - Laserfiche WebLink

Home Browse Search

0 ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGROUND TANK INSTALLATION PERMIT -111111111110 APPLICATION FOR INSTALLATION OF UNDERGROUND TANKS ARE ONLY VALID FOR THE CALENDAR YEAR IN WHICH IT HAS BEEN ISSUED. A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO PHS-EHD REQUESTING THIS EXTENSION THIRTY DAYS PRIOR TO THE END OF THE CALENDAR YEAR. A ONE YEAR -- ONE TIME EXTENSION MAY BE GRANTED BY PHS-EHD UPON RECEIPT OF THIS LETTER. DO NOT WRITE IN ANY SHADED AREAS. imitate the respons mte party to be btLted for additional PHS-EHD staff time expended T!.a party must a i0�adge this responsibility for the addityanat bitting by signature Mail ng Address J o L Day Ph a Number Signature EH 23 008 (Rev 1/7/92) WP the 8 hour minimum installation payment. to below. EPA SITE #C RCGdoG(S-Vs PROJECT CONTACT & TELEPHONE # W'jkg .. F A FACILITY NAME ,RT PHONE # 4 -OeF ZC( 1 C ADDRESS: I L CROSS STREET / T OWNE OPERATOR PHONE # Y Zv -©4 Z C 0 CONTRACTOR NAME c- _vC . r'_ FJ J t PHONE #7z? -Z& 43 7 T CONTRACTOR ADORESl t C, c�.7rr OA L10 !! CLASSC�I R A HAZARDOUS WASTE CERTIFIED YES NO WORK.COMP.# O C' C FIRE OISTRI CT PERMIT # T 0 BOARD OF EQUALIZATION R TANK ID # TANK SIN CHEMIC4LS TO BE.STORED PROPOSED INSTALLATION 39- 1066- c Z /LL'1./1-.f}Z[,Q Lb CE K DATE fY T 39- I(S A 39- N 39- K 39- 39- 39- P IIII L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED A ACHMENT WITH CONDITIONS) N PLAN REVIEWERS NAME �,li-1 2/% 11111111 [1111111111111111 1111111 IRTIIII I I 111111111111 DATE 11111MUM1111 I III I I I I I I I I I I I I I APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR W -H THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATI LA4S CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMA CE THE WORK FOR RICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CA IFORNIA-' APPLICANT'S SIGNATURE: TITLE <Zegf . DATE 1Z-%%-93 imitate the respons mte party to be btLted for additional PHS-EHD staff time expended T!.a party must a i0�adge this responsibility for the addityanat bitting by signature Mail ng Address J o L Day Ph a Number Signature EH 23 008 (Rev 1/7/92) WP the 8 hour minimum installation payment. to below.